Healthcare providers are missing opportunities to prescribe pre-exposure prophylaxis (PrEP) to patients at high risk of HIV, according to US research published in Clinical Infectious Diseases.
The research found that two-thirds of patients sought health care, a quarter because of a sexually transmitted infection (STI), in the period before their infection with HIV. Women, African Americans and younger patients were especially likely to have missed opportunities for PrEP prescribing.
“The finding that ¼ had an STD [sexually transmitted disease] diagnosis at a prior health care visit suggests that clinicians may not be responding to the fact that gonorrhea and syphilis are strongly suggestive for HIV acquisition in both MSM [men who have sex with men] and heterosexually active women,” comment the authors. “The finding that Hispanic/Latino persons were significantly less likely to have a prior health care visit is concerning, given that rates of new infection are rising among young Hispanic/Latino MSM.”
Daily PrEP can reduce the risk of infection with HIV by over 90%. However it’s been estimated that only 10% of individuals in the US who would potentially benefit from PrEP are currently receiving this highly effective method of HIV prevention. Research has also revealed disparities in PrEP provision according to race/ethnicity, HIV risk group, gender and age.
Investigators in South Carolina wanted to see if healthcare providers were missing opportunities to prescribe PrEP to patients at high risk of HIV. They designed a retrospective study involving 885 patients aged 13 years and older who were newly diagnosed with HIV between 2013 and 2016 and who had evidence of recent infection with the virus. Data were gathered regarding attendance at healthcare facilities in the period before HIV diagnosis. The investigators also examined the reasons why the patients sough health care.
Two-thirds of patients visited a healthcare facility in the period before their HIV diagnosis. These patients had a mean of seven healthcare visits. Most of the visits (84%) were to hospital emergency departments. A plurality of visits (42%) involved patients without health insurance or who paid for health care themselves, with 36% having public insurance and 18% private insurance. Few Hispanic/Latino patients made healthcare visits.
Patients with missed opportunities for PrEP prescribing were more likely to be female than male (p < 0.0001), African American than white (p < 0.0001) and younger than 30 years of age (p < 0.0003).
A quarter of patients attended a healthcare facility because of gonorrohea or syphilis, increasing to 29% when chlamydia was added as a reason for seeking health care.
“Although PrEP uptake has been increasing nationwide, its delivery in the southern states where the majority of new HIV diagnoses are now occurring, to African American men and women, and to young Hispanic/Latino men, has been disturbingly low,” conclude the authors. “To urgently address these geographic and demographic inequalities, it is necessary to increase health care utilization among black men and women and Hispanic/Latin men, reduce the number of missed opportunities for HIV testing at all health care visits, and identify indications for PrEP use in HIV-negative persons – especially those with diagnosed bacterial STDs, so that PrEP for HIV prevention can be provided.”
Smith DK et al. Missed opportunities to prescribe preexposure prophylaxis in South Carolina, 2013-2016. Clin Infect Dis, online edition. DOI/10.1093/cid/ciy441/5001363 (2018).